Integrated Care at the Center for Psychology and Health

As APA advanced the professional role of psychology within the reformed health care system, it became clear that integrated care would be a priority. The Affordable Care Act is now moving well into its fourth year, and its provisions will have a direct impact on all health care providers, including psychologists. The new emphasis of payment systems will be on quality and value, words not often previously used in health care. The emphasis on quality changes the traditional model of health care providers working individually with patients to the development of well-organized, multi-disciplinary integrated health care teams that include psychologists. In the near future, reimbursement will be based not only on the number of patients seen but also on the quality of service. New questions will be asked: Did the patient and family receive services that were acceptable to them? Were services accessible by place and schedule? Were the interventions effective?

Whereas quality refers to receiving excellent services when and where needed, value refers to something else: Did the patient receive the best possible service for the price paid? In the past, the payment system emphasized the price paid for service; to increase income, providers either increased the number of services or raised their prices. Prior attempts to reign in health care costs either lowered prices or limited services. But as any good behaviorist can tell you, the reinforcement schedule that pays for services only tends to reinforce more services, not necessarily the best outcome. In addition, this model reinforces insurer decisions to conserve funds by limiting payments.

The paradox of the “good old days” of health care is that if you were not good at helping patients get healthier, you could potentially make more money. On the other hand, if you saw a patient once or twice and they got better, you would make less money. For example, in a program carried out over 25 years ago in a practice serving children with Type I diabetes, a goal was set to reduce re-admissions for diabetic ketoacidosis. To accomplish this, an endocrinologist led a team of multidisciplinary providers including nurse educators, a social worker, and a psychologist. Goals were exceeded with a nearly 50% reduction in re-admissions and a surge of newly referred cases (Glasgow et al. 1991). However the loss of re-admissions lowered revenue. The physicians and psychologist had no emergency department visits or inpatients to bill for, and over time the practice lost significant revenue. Quality and outcome were not rewarded; rather, they compromised profitability. If the team had done poorly and the children remained sick more often, the team would have had more opportunities to bill for services and make more money. By keeping children healthier and out of the hospital, revenue was lost.

A quarter of a century later, the rules are changing. Treatment outcomes are becoming the most important variable, and payers will award bonuses to health care practices that improve outcomes for their patients. We are seeing a full range of program models, particularly in primary care, that show the success of providing appropriate care, including much-needed psychological services. Initial cost increases associated with the new treatment paradigms are quickly followed by reductions in emergency department utilization and hospitalizations. Overall costs are lower, and treatment efficacy is improved. The integrated care model at Cherokee Health Systems is perhaps the best example of this work (www.cherokeehealth.com).

From these emerging models we can conclude that integrated care is more effective, and therefore patients are healthier and overall costs are reduced. This is in marked contrast to systems of the past that attempted to reduce costs by decreasing services. Now, the system has fundamentally changed. The type of diabetes program described above would now earn bonuses for keeping kids out of the hospital. Programs that lower costs by keeping patients healthier will become the standard in the new system.

As psychologists, we know that behavior is the strongest determinant of health. Health habits including nutrition, exercise, sleep, substance use, and risky sexual behavior have a greater influence on a given population’s health than the type of health care services received. We also know that the co-occurrence of commonly diagnosed disorders such as anxiety, depression, or substance abuse with a chronic medical condition will double or triple the costs of care for a patient. Thus, health psychologists have a dual role in the new health care system: caring for patients who have a dual diagnosis to both improve their outcomes and reduce costs, and helping to develop preventative strategies that improve health habits for all patients.

The profession of health psychology is contributing to the evidence base that justifies the inclusion of psychologists in integrated care models. There are many small studies showing our effectiveness in improving outcomes. In my new role leading the integrated care effort at APA, it is my job to gather information from the work of APA members in all health-related divisions. We need information not only on effectiveness, but also on costs. Here at APA we will prepare that information to present to health care organizations, government representatives, insurers, and health care consultant firms to advance integrated care models in both primary and specialty care. The primary role of this new position is to advance our good work scientifically, educationally, and clinically. We have a unique opportunity in this period of rapid implementation in health care reform. Let’s take advantage of it.